A. Ethical Issues

As a practicing nurse, one will come across various challenges that require guidance from the American Nursing Association (ANA) code of ethics. However, the stipulations in ANA’s code of ethics can at times result to ethical dilemmas in actual practice.

As a nurse leader serving on a healthcare organization’s ethics committee, I have come across a few ethical challenges. One reoccurring scenario is when a patient’s beliefs interfere with medical interventions. In one instance, a patient presented with serious external hemorrhaging after being involved in a nasty accident. This type of trauma led to a lot of blood loss that necessitated a blood transfusion as recommended to the patient’s family by the nursing team leader, responsible for prioritizing healthcare delivery especially where time is of the essence. However, the patient’s family informed the care team that the patient’s religion does not allow taking blood in any form into their own body and therefore could not possibly sign off to a blood transfusion. Refusing medical interventions is within the right of every patient to form their own decisions founded on their values and beliefs. A nurse’s primary role to alleviate suffering and enable focus on self-care (Morrell, Konda & Grant-Kels, 2019). The ANA ethics code instructs nurses to respect the patient’s religious beliefs and value systems (American Nurses Association, 2015). This scenario is a bit contradictory as the nurses are not able to perform their care duties while still respecting the patient’s decision to refuse medical intervention.
Another frequent scenario that occurs in my organization involves dealing with next of kin imposing opposing medical opinions. One case I recall is when a patient who was at end of life had signed a do not resuscitate (DNS) order but the next of kin, the family, were actively beseeching the care team to initiate resuscitation as the patient health was deteriorating. An ethical dilemma thus develops due to the contradicting provisions in ANA’s code of ethics. The code states that nurses have a mandate to promote and protect a patient’s health and safety. The same code of ethics also states that a nurse’s primary focus is to the patient and in certain cases, this includes the patient’s family (American Nurses Association, 2015). Therefore, the family is owed a duty as they are the next of kin and the decision maker, acting as a surrogate on behalf of the patient with no capacity to do so themselves(DeMartino et al., 2017). An ethical challenge arises as the nurse is obligated to keep the patient’s wishes while also respecting the family’s role in the decision making-process, both of which contradict each other. It is even more complex when a patient has made no medical decision while incapacitated and the next of kin is either unaware or is unwilling or unable to express or implement the patient’s wishes (Strøm & Dreyer, 2018).

A1. Legal Considerations

In the first scenario, providing medical care against a patient’s beliefs could lead to legal consequences such as violating the first amendment that protects a patient’s freedom of religion. In some cases, the patient might sue citing emotional distress.

In the second scenario regarding whether or not to respect the patient’s decision or the family’s decision concerning resuscitation, the healthcare organization could face a malpractice lawsuit for violating a DNS order. The family could also deem the care team’s lack of action as medical negligence and sue for malpractice.

A2. Supporting Research

The challenge of delivering care to patients whose religious beliefs or otherwise interfere with the medical procedures prescribed like in the first case has been encountered before and fits the autonomy and paternalism discussions. Autonomy refers to the patient’s right to make decisions without influence from their care providers (DeNisco & Barker, 2016). On the other hand, when care providers make decisions for patients with the capacity to do so themselves, it is called paternalism. It is born from a need to do good and based in a person’s belief that they are best placed to decide what is beneficial for the other person. This violates patient autonomy. Despite it being the physician’s responsibility to determine a patient’s capacity for decision-making, it is upon the nurse to effectively evaluate the patient and forward the results to the provider for additional assessment. Healthcare providers should make sure that patients get an opportunity to share their spiritual and religious beliefs and adjust their assessment and treatment options to align with their unique needs (Swihart, Yarrarapu & Martin, 2020).
In the second scenario dealing with opposing medical opinions from medical representatives of a patient, the autonomy of the patient is violated. Another present issue that presents mainly at end of life is the right to a dignified death. Palliative care involves caring for the dying in an active and sympathetic manner (Oechsle, 2019). Death of a patient often involves organizing numerous practicalities carried out mostly by relatives, medical personnel and caregivers to ensure appropriate living standards until death intervenes. Nurses have a duty to respect the directives of the patient regarding end of life. In some cases, they may be swayed by their empathy or succumb to persuasion from family members with requests contrary to that of the patient creating an ethical challenge. Nurses must be aware of the mental anguish that overcomes them in situations such as these where they may be unable to provide care they feel is needed (Denisco & Barker, 2016).

B1. Nurse’s Responsibility
A nurse leader’s role within a healthcare organization is to protect the best interests of the patient by presenting to the ethics committee the necessary information required to make informed decisions with the most manageable risks. Designing an ethical framework is a good place to start as it provides a common-ground for problem solving and patient collaboration. Another step to ensure ethical practice would involve nurse leaders electing champions to facilitate the decision process. Ethical leadership should be guided by ethical nursing principles of autonomy, fidelity, veracity, non-maleficence, justice and beneficence(Henry et al., 2016).The Situation Assessment Procedure can be applied to the first scenario. The first step in this model is identifying the ethical issue. The ethical problem here is the nurse’s primary care delivery role versus the need to respect the patient’s autonomy and religious beliefs. The issues are violating the patient’s first amendment and the probability of causing emotional distress on the patient. Identifying alternative actions is the second step. Here, alternative medical interventions include hypervolemic hemodilution, red blood cells substitutes, autologous blood transfusion, pharmacological interventions and cell savers (Chand, Subramanya & Rao, 2014). After analyzing all the available options, the decision can be made and then justified. In this case, the patient was willing to try autologous blood transfusion since it was safer and cheaper and solved the issue of coming into contact with another person’s blood.

B2. Stakeholders

The stakeholders in this process include the patient, the physician, the nurses, the nurse leader and the ethics committee. The patient includes the family if available and fit to make decisions on behalf of the patient. If none is available, the ethical committee will make the decision. The nurses are responsible for monitoring and reevaluating the patient’s mental faculties for changes in the ability to make these decisions. The nurse leader then communicates the same to the physician and the ethical committee with whom the final decision lies with. Once discharged, the family members or care givers may be tasked with caring for the patient.

B3. Role of Interdisciplinary Team

The interdisciplinary team consists of the ethics committee, the physician, the nurse leader and the nurse team. The physician plays a key role due to their medical experience and prowess necessary to make decisions in areas such as diagnosis, medical interventions and assessing a patient’s decision-making abilities. The nursing team is tasked with monitoring the patient for any changes relevant to his/her decision making. The nurse leader is in charge of supervising the care process and is often responsible for communication between the patient, the family members and other staff members. The ethics committee is responsible for making the decision that caters for the interests of the parties involved by analyzing the information presented to them and considering the legal consequences.

B4. Leadership Strategy

A nurse leader may incorporate different tactics to ensure an efficient decision-making process. One method includes empowering the rest of the team to work in tandem and achieve a common objective. This ensures that each person is aware of their responsibilities and is accountable for achieving their goals in the process. By doing so they server as role models and challenge other team members to find creative solutions to unique ethical dilemmas. In doing so, they motivate the team to achieve goals that align with the organization’s mission or vision (Kotalik et al., 2021).

C. Mission Statement Alignment

My healthcare’s mission is to promote health through high-quality and outstanding patient care. This is in line with the leadership strategy, the ethical framework and the decision-making process revealed in the healthcare scenarios discussed. By systematically reviewing each case, incorporating an interdisciplinary team and making sure all the parties involved are considered in the final decision, a healthy and safe environment is created for the patient and any others in the future. This framework is the connection between the organization’s day-to-day operations and its mission (Kotalik et al., 2021).

References

American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Silver Spring, Md.: American Nurses Association.

Chand, N., Subramanya, H., & Rao, G. (2014). Management of patients who refuse blood transfusion. Indian Journal Of Anaesthesia, 58(5), 658. doi: 10.4103/0019-5049.144680

DeMartino, E., Dudzinski, D., Doyle, C., Sperry, B., Gregory, S., & Siegler, M. et al. (2017). Who Decides When a Patient Can’t? Statutes on Alternate Decision Makers. New England Journal Of Medicine, 376(15), 1478-1482. doi: 10.1056/nejmms1611497

DeNisco, S., & Barker, A. (2016). Advanced practice nursing (3rd ed.). Burlington, MA: Jones and Bartlett Learning.

Henry, N., McMichael, M., Johnson, J., DiStasi, A., Ball, B., & Holman, H. et al. (2016). Nursing leadership and management (7th ed., pp. 47-48). Assessment Technologies Institute, LLC.

Kotalik, J., Covino, C., Doucette, N., Henderson, S., Langlois, M., McDaid, K., & Pedri, L. (2021). Framework for Ethical Decision-Making Based on Mission, Vision and Values of the Institution. Retrieved 25 February 2021, from

Morrell, T., Konda, S., & Grant-Kels, J. (2019). Response to a letter to the editor regarding “The ethical issue of cherry picking patients”. Journal Of The American Academy Of Dermatology, 80(5), e127. doi: 10.1016/j.jaad.2018.07.053

Oechsle, K. (2019). Current Advances in Palliative & Hospice Care: Problems and Needs of Relatives and Family Caregivers During Palliative and Hospice Care—An Overview of Current Literature. Medical Sciences, 7(3), 43. doi: 10.3390/medsci7030043

Strøm, A., & Dreyer, A. (2018). Next of kin’s protracted challenges with access to relevant information and involvement opportunities. Journal Of Multidisciplinary Healthcare, Volume 12, 1-8. doi: 10.2147/jmdh.s183946

Swihart, D., Yarrarapu, S., & Martin, R. (2020). Cultural Religious Competence In Clinical Practice. Retrieved 25 February 2021, from https://www.ncbi.nlm.nih.gov/books/NBK493216